Provider Demographics
NPI:1689938417
Name:CANNON, GRETE K (OT)
Entity Type:Individual
Prefix:
First Name:GRETE
Middle Name:K
Last Name:CANNON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 80217
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85060-0217
Mailing Address - Country:US
Mailing Address - Phone:602-385-2115
Mailing Address - Fax:480-418-3323
Practice Address - Street 1:3033 N 44TH ST STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-7227
Practice Address - Country:US
Practice Address - Phone:602-631-3161
Practice Address - Fax:602-631-3162
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5441225X00000X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ806851Medicaid
WA0295842OtherL & I
WA0295846OtherL & I
AZ806851Medicaid
WAG8911599Medicare PIN
WAG8912681Medicare PIN
AZZ158424Medicare PIN
AZ806851Medicaid
WAG8912680Medicare PIN
WAG8911598Medicare PIN